Exploring Strategic Change with your Boards of Directors

Transcription

1 Exploring Strategic Change with your Boards of Directors Presented by: Kandy Ferree, President & CEO 360 Strategy Group Anne Donnelly, Director of Health Care Policy Project Inform

2 State of the science, cutting edge information presented by expert practitioners Broad range of topics including Access to Care Health Care Reform Harm Reduction Advocacy series Retention in Care AU Commitment to Informing the Field Sector Transformation series including Changing Healthcare Environment, CBO Sustainability, and Board Engagement Today s webinar is part of our Sector Transformation series Navigating the New Reality (last month) Remaining Relevant (last month) Board Engagement Limited resources available to help CBOs decide whether to merge, grow, or go responsibly (Contact Stephanie Cruse, scruse@aidsunited.org) Stay tuned for our new website debut in June!

3 Webinar Instructions All attendees are in listen-only mode Everyone can ask questions at any time using the question/chat feature This webinar has too many attendees for questions to be submitted over the phone During Q & A segment, the moderators will read questions that have been submitted

4 Use the Question Feature to Ask Questions or Questions.

5 Webinar Acknowledgements Funded by: AIDS United and Johnson & Johnson Contributors: Anne Donnelly Kandy Ferree Acknowledgements: Project Inform 360 Strategy Group Countless direct service providers and people living with HIV/AIDS from whom we have learned so much and contributed to this presentation.

6 Presentation Overview Overview of the HIV/AIDS and Healthcare Landscape Overview of the Affordable Care Act (ACA) at the national level Discussion of important implications and choices facing AIDS Service Organizations The role of Boards

7 Part 1 EXPLORING STRATEGIC CHANGE HIV/AIDS AND HEALTHCARE LANDSCAPE

8 Ask Yourself: Do I have the courage to Lead? We did not come to fear the future. We came here to shape it. PRESIDENT BARACK OBAMA Speech to Joint Session of Congress September 9, 2009

9 High-Impact Prevention G#1: Reduce HIV Infections G#2: Increase Access to External Care G#3: Environment Reduce Health Disparities INCREASE POSITIVE HEALTH OUTCOMES State Budget Deficits Medicaid Expansion or NOT?

10 Where States Stand on Medicaid Expansion Source: Kaiser Family Foundation

11 Medicaid Expansion & HIV

12 HIV/AIDS Treatment Cascade Major Gap: Testing & Identification Major Gaps: Linkage Retention

13 QUANTITY Change is Constant Transformation is Not (at least historically) NHAS RWCA HCR/ACA State Budgets Funder Priorities Speed Constant Transformation Frequency

14 2 KEY ELEMENTS CRITICAL FOR ASO TRANFORMATION Healthcare Organization that Ensures PLWH/A have access to and get the most benefit from Medical Care & the Services that Facilitate Optimum Health Outcomes BUSINESS MODEL (Financing) IDENTITY (Founders & Brand) AIDS Service Org Harm Reduction Org Syringe Exchange Program

15 THE CHOICES & STAGES IN THE HEALTHCARE REFORM AND AIDS SERVICES PARADIGM SHIFT

16 Part 2 AFFORDABLE CARE ACT & HEALTH CARE REFORM IT S A PROCESS NOT AN EVENT & ONLY PART OF THE PICTURE

17 What Does HCR Do? Component Requires Most Individuals to Have Insurance Coverage U.S. (Federal) U.S citizens and legal residents must maintain health coverage or face a tax penalty (some exemptions ) Expands Coverage: Focus on the Uninsured State option to expand Medicaid Federal or state-run Insurance Marketplace in all states Creates Essential Health Benefits Examples: (see list in resource slides) Ambulatory Care, Emergency Care, Hospitalization Prescription Drugs Increases Access to Preventive Care Examples: (see list in resource slides) HIV screening ( everyone age 15-65) Hepatitis C screening (for high risk adults) Helps with Costs Subsidies for lower income people in marketplace Out of pocket caps on coverage for all Reforms Private Insurance: Creates New Protections Eliminates denials and increased premiums for pre-existing conditions; no annual or lifetime limits on coverage

18 Health Care Reform Encourages Component Selected Examples Coordinated Care Accountable Care Organizations (ACOs) PCMH/Medicaid Health Homes ASOs can use RWCA funds now to build a case that your services (i.e. Linkage, Medical C/, retention) are cost effective or should be reimbursable Increased Quality & Focus on Health Outcomes Strengthening the Health care Workforce Health Care Innovation Awards Pay for Performance Programs Bundled Payments for Care Improvements Increased Medicaid reimbursement rates for primary care providers OTHER.

19 Looking More Closely at Coverage Expansion Medicaid Expansion 26 states have adopted 0-138% of FPL (Approx. $15,800 individual; $32,500 family of 4) Covers low-income adults without children, even if they are not disabled No asset test Private Insurance Marketplaces All states Website to compare and select private insurance plans Any income level: % FPL get some help with premiums & out of pocket costs $11,500 individual; $23,500 family of 4 $28,700 individual; $46,000 family of 4 Enrollment deadlines differ Marketplace - March 31, 2014 Medicaid - enrollment at any time 250% - 400%FPL get help with premiums 19

20 Medicaid Expansion & PLWH

21 Alternative Medicaid Expansion Plans: Medicaid Premium Assistance Programs Traditional Medicaid State decides to expand Medicaid to people with income up to 138% FPL (Yay!) How to structure the expansion?? Alternative Benefits Plan that could be different from traditional Medicaid Premium assistance program to purchase Qualified Health Plans (QHPs) for Medicaid beneficiaries

22 Weighing the Pros and Cons of Premium Assistance Plans The Good Politically feasible way to get state to expand Medicaid Reduces churn between Medicaid and QHPs May allow access to bigger provider networks The Concerns May weaken Medicaid oversight and protections May weaken the benefits provided by Medicaid programs States are using 1115 waivers to ask for even more flexibility from Medicaid rules Could threaten the entitlement nature of Medicaid

23 The ACA Ryan White Conundrum Transformation of the HIV care and delivery system Most uninsured and underinsured PLWH depend on RW RW became its own system of care As more coverage options open up through HCR, more people with HIV will have to change coverage RW is a payer of last resort: Can t pay for services that can be provided under other coverage Transitions to new plans, providers, pharmacies

24 Continued Need for RW Services 70% of people currently on RW have some type of insurance and still need RW to fill gaps Critical services not covered in most insurance plans: Outreach, HIV testing, referral & linkage to care Dental, vision, specific types of case management, navigation assistance with new coverage, adherence, linkage to housing, food, transportation Help with Affordability: Insurance Premiums & Outof-pocket costs for care and medications

25 Ryan White PAYER of LAST RESORT : HRSA Requirements for Health Care Reform For every RW funded client your organization MUST: 1. Make every effort to enroll RW clients in other insurance coverage or payer options 2. Document your efforts to do so Language from HRSA Guidance: RW funds cannot be used for items or services for which payment has been made or can reasonably be expected to be made by another source. (PHS Act) Grantees must vigorously pursue enrollment, make every effort to enroll clients, document their efforts to enroll clients, etc. HRSA enforces the requirement through audits; organization could be liable to repay HRSA for care provided under RW that could have been paid for by a different program 25

26 RW - Continuity of Care Interpretation of Payer of Last Resort guidance varies across jurisdictions Follow developments in your state/locale Be prepared to challenge interpretations that may negatively impact clients Ryan White programs will and must continue to serve clients who are not enrolled in other coverage The priority must be to ensure clients don t drop out of care and have access to appropriate high-quality care 26

27 Ryan White Program & Funding WILL Change! RW will continue for uninsured RW will offer less primary care and more care completion services More likely to have to justify RW funding and services by outcome & support of health and well being Ryan White funding is likely to decrease in the long run CBOs need to: innovate, ensure services remain relevant, credential and professionalize staff, demonstrate & document health outcomes & diversify funding sources

28 Ryan White Program Client Transitions 2014 ACA Coverage Option Income Eligibility Threshold ADAP Clients Served, by Income Level (June 2012) % FPL 6% >400% FPL 2% Unknown <1% % FPL 15% % FPL 19% % 100% FPL FPL 45% 14% NASTAD Annual ADAP Monitoring Report, January 2013 Medicaid Expansion Advance Premium Tax Credit for purchase of private insurance through exchanges/marketplaces Cost-sharing subsidies to offset out-of-pocket costs of private insurance through exchanges/marketplaces Unsubsidized private insurance coverage through exchanges/marketplaces Income up to 138% FPL Income between 100 and 400% FPL (ineligible for Medicaid or affordable employer-based coverage) Income between 100 and 250% FPL (ineligible for Medicaid or affordable employer-based coverage) Income below 100% FPL (ineligible for Medicaid) Essential to also focus efforts on those outside of the Ryan White Program/ADAP systems of care to address unmet need and health disparities

29 Adapted from West Virginia Ryan White Part B Program Assessing and Filling Gaps in Coverage HIV Testing RX MEDICAL CASE MANAGEMENT ORAL HEALTH SERVICE QHP MEDICAID RW/ ADAP/CDC Continue to cover in certain settings Cost-sharing assistance and gap coverage LABS MENTAL HEALTH SERVICES SUBSTANCE ABUSE TREATMENT HIV PRIMARY CARE Cost-sharing assistance Cost-sharing assistance and in some settings care continuation Cost-sharing assistance and in some settings care continuation Cost-sharing assistance MEDICAL TRANSPORTATION INPATIENT HOSPITAL SERVICES Limited Coverage

30 Example: Case Management Coverage Private Insurance Benchmark Plan Case management Periodic phone calls to discuss appointments and assist in finding services. Ryan White Program Medical case management Coordination and follow-up of medical treatments, ongoing assessment of the client s and other key family members needs and personal support systems, development of a service plan, coordination of services, provision of treatment adherence counseling to ensure readiness for, and adherence to HIV/AIDS treatments. Non-medical case management Includes provision of advice and assistance in obtaining medical, social, community, legal, financial, and other needed services (does not include coordination and follow-up of medical treatments).

31 Some Ongoing Issues That NEED our Attention Health care delivery advocacy is increasingly important and needed in more areas. The best policy decisions are made with provider input: Continuation of the Ryan White program RW to ensure safe transitions from one payer source to another Remains relevant to unique needs of PWLHA Serves those most in need Medicaid expansion in all states Ensure that Medicaid, Medicare and private insurance systems deliver quality HIV services Adequate reimbursement rates for providers of a continuum of services in patient centered medical home models Health care for undocumented and residually uninsured individuals More affordability for low income individuals with chronic conditions Ensuring providers and clients understanding the rights to access to benefits and services in insurance plans Possible opportunity for more community based organizations to build policy/advocacy skills and funding

32 Part 3 THERE ARE AT LEAST THREE MAJOR REALITIES ASO S NEED TO PREPARE FOR

33 REALITY: Growth in Coordinated Care Patient Centered Medical Home (PCMH) or Medicaid Health Home (MHM) NCQA sets standards around organizing primary care around patients, working in teams and coordinating and tracking care over time. (Note: HIV Could be one Area of Accreditation) Triple AIM a core strategy: Improve the health of the defined population Reduce, or at least control, the per capita cost of care Enhance the patient care experience (including quality, access and reliability) The Institute for Healthcare Improvement (IHI) IMPACT: CBOs may be able to partner with clinical sites to expand services & improve linkage, retention and coordination. Use RW to build partnerships NOW!

34 REALITY: Growth in the Use of Electronic Health Record (EHR) The promise of EHR (electronic health records) is that if its use is meaningful then benefits will result in the form of complete and accurate information to enable better care, better access to this information in order to diagnose health issues earlier, and patient empowerment with patients playing a bigger role in their health care. Medicare and Medicaid have provided incentive payments to CHCs when they adopt certified EHR technology in order to promote these benefits. Meaningful use is expected to evolve progressively over three stages. IMPACT: Massive Capacity, Cost, and Infrastructure Issues for ASOs

35 REALITY: Clients Will Have More Choice Under HCR patients will have an expanded choice of medical providers. Emphasis on human resources Accountability Engagement Integrity Process improvements Time to appointment Wait time Appropriate counseling of clients IMPACT: Patient Choice will require agencies to attend to quality and client satisfaction to survive. CBOs may be valuable partners.

36 SO WHAT? NOW WHAT?

37 Darwinism: If you don t evolve, you become extinct. We re building it WHILE we fly it... We ve DONE This Before!

38 4-Stage Sector Transformation Process EDUCATE CHANGES: Policy Financing Service Delivery Systems ISSUES: Identity Business Model SKILLS: Advocacy Scenario Planning Succession Planning ENERGIZE Assess Organizational Readiness Executive Director Board Staff Clients Develop an Agency Plan Engage National & Local Funders Build Trust Move to Action EXPLORE Actively support organizations to: explore options identify possible partners test feasibility DECISION Merge Grow Go EXECUTE Actively support organizations to engage in a structural transformation process Collaborations Business Model Conversion (ASO to FQHC) Strategic Alliances Strategic Restructuring Responsible Closure

39 IMMEDIATE ACTION: DEVELOP A COMPRHENSIVE AGENCY PLAN 1. Landscape: Understand the specifics and the timelines for changes in your state. 2. Staff: Training, coordination, capacity & expertise assessment 3. Clients: 1. Know your client base & their evolving needs 2. Help clients with new coverage, enrollment, transitions, navigation, and troubleshooting access issues 4. Business/Funding Plan 39

40 An ASO s Historical Services become. Transferrable Skills or Sellable Commodities BUT only with Measurable Outcomes & Clear Understanding of Service Costs Client/Patient/Participant Outreach Adherence Linkage Vs. Referral Retention: Primary Care & Specialty Care Patient or AHP Enrollment Supportive or Facilitative Services Education: Insurance, Disease, progression, Tx Options, etc.

41 Current Business Model New Business Model ASO Sector Transformation Model Collaboration: Info Sharing Referrals Joint Planning Responsible Closures (To Ensure Continuity of Care!!!!) Founding Identity Strategic Alliances To Develop New Service Models: Admin. Consolidation Formal Co-education Preferred Provider Referrals Resource Sharing/Contracting Cash, Staff, EHR, etc. Co-location Integration w/ Primary Care ASO to FQHC Conversion Strategic Restructuring: Management Services Org (MSO) Parent - Subsidiary Mergers Acquisitions Joint Ventures Evolving Identity

42 CHOICES..

43 Lessons from Pioneering ASOs Relevance + positioning = sustainability Never underestimate the value of relationship capital Readiness planning is critical STAFF, BOARD and CLIENTS Take time for strategic thinking... be proactive, forecast and don t do it in a bubble Know the data, the drivers and the deliverables required Be willing to take smart, calculated risks Must constantly evolve the way you do business evolve or become extinct Power of advocacy and policy. ACTION CHANGES THINGS!

44 THE BOTTOM LINE MERGE Consolidate Administration/Infrastructure Leverage Program Expertise Create new service model or Continuum GROW Remain Stand Alone Expand Mission to include other Populations, Services or Geographies GO CLOSE RESPONSIBLY! Conscious Decision Notify and Work with Funders to Transfer Grants/Contracts WORK PROACTIVELY to TRANSITION CLIENTS to Other Providers! CONTINUITY OF CARE!!!!!

45 Which will you Choose?

46 Acknowledgements AIDS United Johnson & Johnson Anne Donnelly Project Inform Kandy Ferree 360 Strategy Group Liz Brosnan Christie s Place Countless direct service providers and people living with HIV/AIDS from whom we have learned so much and contributed to this presentation.

47 THANK YOU!

48 Questions Ask your questions using the webinar question feature. If we don t get to your question it will be logged and we ll do our best to follow up!

49 What s Next Download & share the presentation and webinar recording (available in a few days) We need your feedback! When you sign off, take the quick survey about the webinar Watch for future webinar announcements

50 Thank You Kandy Ferree, President & CEO 360 Strategy Group Anne Donnelly, Director of Health Care Policy Project Inform For more information about sector transformation, please Stephanie Cruse, Program Manager AIDS United

51 Exploring Strategic Change with your Boards of Directors Presented by: Kandy Ferree, President & CEO 360 Strategy Group Anne Donnelly, Director of Health Care Policy Project Inform